VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Herndon Harbor Adult Day Health Care Center
875 Grace Street
Herndon, VA 20170
(703) 435-8729

Current Inspector: Ishmel Paige (804) 963-0360

Inspection Date: Oct. 17, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

N/A

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/17/2024 9:35 AM to 12:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with participants:1 Number of interviews conducted with staff: 4 Observations by licensing inspector: meals, activities, medication pass. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-90-A
Description:	Based on center document review and staff interview, the center failed to report to the regional licensing office within 24 hours of the occurrence of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any participant. Evidence: 1. Staff 1 provided the incident report binder. 2. The incident report binder contained 7 incident reports that were not sent to the licensing office. The incident reports included one (1) disruptive behavior leading to an injury of another participant ? dated 10/09/2024, four (4) falls with injury ? dated 10/09/2024, 06/07/2024, and (2) 05/20/2024, 06/07/2024 , and two (2) problems of health/medication ? dated (2) 07/10/2024. 3. The incident report binder contained a document that said ?Incident Report Checklist? that detailed action steps to take. Under ?Within 24 hours of Incident?, it states ?Send a draft summary of incident report to [Job Title] for review and approval prior to sending it to DSS Regional Licensing Inspector, [Previous LI?s name].? The next line says, ?Send brief summary of incident by e-mail to [Previous LI?s name and email] at licensing and copy [Job Title] addressing the following issues: name of center, name of participant, name of person making report?, date of incident, description of incident, action(s) taken in response of incident? 4. In an interview with the LI on 10/17/2024, Staff 1 confirmed that these reports were not submitted to the licensing office.
Plan of Correction:	A. Herndon ADHC will report to the regional licensing office within 24 hours of the occurrence of any major incident that has negatively affected or threatened the life, health, safety, or welfare of any participant. B. The report required in subsection A of this section shall include (i) the name of the center, (ii) the name of the participant involved in the incident, (iii) the name of the person making the report, (iv) the date of the incident, (v) a description of the incident, and (vi) the actions taken in response to the incident. C. The center shall submit a written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident. The report shall be signed and dated by the director or his designee and include the following information: 1. Name and address of the center; 2. Name of the participant involved in the incident; 3. Date and time of the incident; 4. Description of the incident, the circumstances under which it happened, and when applicable, extent of injury or damage; 5. Location of the incident; 6. Actions taken in response to the incident; 7. The outcome of the incident; 8. Actions to prevent recurrence of the incident if applicable; 9. Name of staff person in charge at the time of the incident; 10.Names, telephone numbers, and addresses of witnesses to the incident if any; and 11.Name, title, and signature of the person making the report, if other than the director or his designee. D. The center shall submit to the regional licensing office amendments to the written report when circumstances require, such as when substantial additional actions are taken, when significant new information becomes available, or when there is resolution of the incident after the submission of the report. Herndon ADHC started sending incident reports to DSS licensing inspector on 12/16/2024, the first incident after the inspection.
Standard #:	22VAC40-61-510-A
Description:	Based on center document review and staff interview, the center failed to ensure that an at least an annual inspection by the appropriate fire official was conducted. Evidence: 1. Staff 1 provided the previous fire inspection report for 05/01/2023. 2. In an interview with the LI on 10/17/2024, Staff 1 confirmed that the fire inspection had not been scheduled yet.
Plan of Correction:	Herndon ADHC will comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) and fire inspection will be done at least annually by the appropriate fire official. Herndon ADHC?s fire inspection was done on 11/12/2024 and a copy of the report was emailed to DSS licensing inspector on 11/12/2024. Next inspection is scheduled on in 11/2025.